Most people feel anxious at times. Most will also have their ups and downs. It is natural for a person's mood or anxiety level to change when a stressful or difficult event occurs in his or her life. However, some people experience feelings of anxiety or depression, or suffer mood swings, that are so severe and overwhelming they interfere with their personal relationships, their work and their ability to function on a daily basis. These people may be suffering from an anxiety disorder, bipolar disorder or both.

It is not uncommon for someone with an anxiety disorder to also suffer from bipolar disorder or vice versa. In fact, the majority of people with bipolar disorder will suffer from at least one anxiety disorder at some point in their lives. The good news is that these disorders are both treatable - separately and together. Read on to find out more about the co-occurrence of anxiety and bipolar disorder and how they can be treated.

What is an anxiety disorder?

Anxiety disorders are a unique group of illnesses marked by persistent, excessive and irrational anxiety. These disorders include generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), social anxiety disorder (SAD) and specific phobias. For more information about anxiety disorders, click here.

What is bipolar disorder?

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person's mood, energy and ability to function. The mood swings associated with the disorder are dramatic - from overly "high" and/or irritable to sad and hopeless, and then back again. Often, people with bipolar disorder experience periods of normal mood in between. Severe changes in behavior go along with the changes in mood. These periods of highs and lows are called episodes of mania and depression.
Signs and symptoms of mania (or a manic episode) include:

• Increased energy, activity and restlessness
  
• Excessively "high," overly good, euphoric mood
  
• Extreme irritability
  
• Racing thoughts and talking very fast, jumping from one idea to another
  
• Distractibility, inability to concentrate well
  
• Little sleep needed
  
• Unrealistic beliefs in one's abilities and powers
  
• Poor judgment
  
• Spending sprees
  
• A lasting period of behavior that is different from usual
  
• Increased sexual drive
  
• Abuse of drugs, particularly cocaine, alcohol and sleeping medications
  
• Provocative, intrusive or aggressive behavior
  
• Denial that anything is wrong
  

A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for one week or longer. If the mood is irritable, four additional symptoms must be present.

Signs and symptoms of depression (or a depressive episode) include:

• Lasting sad, anxious or empty mood
  
• Feelings of hopelessness or pessimism
  
• Feelings of guilt, worthlessness or helplessness
  
• Loss of interest or pleasure in activities once enjoyed, including sex
  
• Decreased energy, a feeling of fatigue or of being "slowed down"
  
• Difficulty concentrating, remembering, making decisions
  
• Restlessness or irritability
  
• Sleeping too much, or having trouble sleeping
  
• Change in appetite and/or unintended weight loss or gain
  
• Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury
  
• Thoughts of death or suicide, or suicide attempts
  

A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of two weeks or longer.

It can be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call "the blues" when it is short-lived but is termed "dysthymia" when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania that may feel good when the person experiences it), and then severe mania (which may include symptoms of psychosis such as hallucinations or delusions).

However, in some people, symptoms of mania and depression may occur together in what is called a "mixed" bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.

Read more about bipolar disorder in adults and children and teens.

How can I tell if I have both an anxiety disorder and bipolar disorder?

According to Naomi Simon, MD, associate director of The Center for Anxiety and Traumatic Stress Disorders at Massachusetts General Hospital and assistant professor in psychiatry at Harvard Medical School, making a diagnosis of anxiety plus bipolar disorder can be confusing, and it is best to seek help from a mental health professional. But, Dr. Simon says, there are a few clues that may suggest the presence of both an anxiety disorder and bipolar disorder:

1. The presence of panic attacks and/or significant anxiety, nervousness or worry, or fearful avoidance of activities in addition to periods of depression and mania or hypomania.
   
2. The development of symptoms as a child or young adult (people with both disorders are more likely to report this, although it is not always the case).
   
3. Significant problems with sleep and persistent anxiety even when not in a manic state for those with bipolar disorder, and lack of response to initial treatment all may be clues that more than just an anxiety disorder or bipolar disorder alone are present.
   
4. Increased sensitivity to initial side effects of medication, and a sometimes longer time frame for finding the right medication combination and dosing (although, again, this is not always the case). (Sometimes starting at lower doses and increasing more gradually can help people get to the medication doses they need to get better.)

What is the course of bipolar disorder?

Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some lingering symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment.

The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men.

People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated. Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared. But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.

It is important to note that some people with bipolar disorder become suicidal. Anyone who is thinking about committing suicide needs immediate attention from a mental health professional or a physician. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide.
For more, click here. (http://www.nimh.nih.gov/publicat/bipolar.cfm#intro)

Does suffering from both disorders complicate a patient's condition?

Suffering from both an anxiety disorder and bipolar disorder has been associated with poorer functioning, poorer quality of life, greater likelihood of substance abuse and greater likelihood of suicide attempts than suffering from one of the disorders alone. One of the common symptoms of an anxiety disorder, insomnia, is a major trigger for manic episodes and destabilization of bipolar disorder. This makes it essential for patients to be treated for both their anxiety disorder and bipolar disorder to fully achieve wellness.

How are patients with both disorders treated?

Treatment for co-occurring anxiety and bipolar disorder is more complex than treatment of one of these disorders alone. This makes it essential to carefully consider all of your treatment options with your doctor or mental health provider. People with both disorders may choose medication, therapy or a combination of both to treat their condition.

Medication
When treating co-occurring anxiety and bipolar disorder with medication, most doctors will prescribe a "mood stabilizer" first to address the bipolar disorder. Starting an antidepressant, which are commonly used to treat anxiety disorders, before mood stabilization is achieved can worsen the symptoms associated with an individual's bipolar disorder. However, even when initiated after a mood stabilizer, antidepressants can sometimes trigger manic episodes in someone with bipolar disorder, which as noted above can cause people to engage in risky behaviors such as drug use and unprotected sex. Therefore, doctors sometimes avoid prescribing antidepressants or prescribe them at lower doses in patients with co-occurring anxiety and bipolar disorder than someone with an anxiety disorder alone. People who are using both a mood stabilizer and an antidepressant to treat their condition should be monitored carefully by their doctor for symptoms of mania or hypomania.

Another class of drugs used to treat anxiety disorders, benzodiazepines, do not appear to have negative effects on bipolar disorder and are thus sometimes used for anxiety in patients with co-occurring bipolar disorder. However, benzodiazepines also may cause some side effects, such as physical dependence and tolerance (meaning there is a need for more and more of the medication over time), and there is some risk of abuse particularly for people who have had problems with alcohol or substance abuse. These are points to discuss with a doctor as well. It can sometimes take trying a few different combinations to find the most effective mix for an individual.

Therapy
Research and clinical experience support that for the best outcome, it is important that people with bipolar disorder receive medication to help with "mood stabilization," but therapy also has an important role. Anxiety disorders can be treated either with therapy, medication or a combination of both. Thus, using an evidence-based psychotherapy such as cognitive-behavioral therapy (see below) instead of medication to address the anxiety disorder may offer the benefit of reducing concerns about side effects from using both mood stabilizers and anti-anxiety medications. Forms of therapy include:

• Behavior Therapy. The goal of behavior therapy is to modify and gain control over unwanted behavior. The individual learns to cope with difficult situations, often through controlled exposure to them.
  
• Cognitive Therapy. The goal of cognitive therapy is to identify, challenge, and change unwanted, unproductive thoughts, feelings and behaviors. The individual learns to separate unrealistic thoughts and feelings from realistic ones. As with behavior therapy, the individual is actively involved in his or her own recovery.
  
• Cognitive-Behavior Therapy (CBT). Many therapists use a combination of cognitive and behavior therapies. This is often referred to as CBT. With CBT, the patient learns recovery skills that are useful for a lifetime.
  
• Family therapy. Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person's symptoms.
  
• Relaxation Techniques. Relaxation techniques may help individuals develop the ability to more effectively cope with the stresses that contribute to anxiety and mood, as well as with some of the physical symptoms associated with them. The techniques taught include breathing re-training, progressive muscle relaxation and exercise.
  

To learn more about treatment options, click here.

How do I find a therapist to treat anxiety and bipolar disorder, and what questions should I ask?

ADAA offers a searchable listing of mental health providers nationwide. To find a therapist in your area, click here. Mental Health America also offers a searchable list of therapists, which can be found here.

To determine whether a particular provider may be right for you, consider asking the following questions during your initial consultation:

• What training and experience do you have in treating anxiety disorders and bipolar disorder?
  
• What is your basic approach to treatment?
  
• Do you recommend treating the anxiety first or the bipolar disorder?
  
• How do you manage treatment if I am seeing another doctor/therapist for treatment as well?
  
• Can you prescribe medication or refer me to someone who can?
  
• How long is the course of treatment?
  
• How frequent are treatment sessions and how long do they last?
  
• Do you include family members in therapy?
  
• Will it be possible to reach you after hours in the event of an emergency or crisis?

For more questions to ask and information on treatment options, click here.

What other steps can I take to help reduce my anxiety and regulate my mood?

• Join a support group. Support groups can be an invaluable resource for recovery and empowerment. They involve people with similar needs or experiences, and are facilitated by a consumer, layperson or survivor. Self-help groups for anxiety disorders can be found here. Self-help groups can also be found on the Depression and Bipolar Support Alliance's website here.
  
• Exercise regularly. Exercise can have a beneficial effect on anxiety and mood disorders (such as bipolar disorder and depression) because chemicals released during exercise have a stabilizing effect on mood. Set a goal of 30-40 minutes of activity three times a week. Try biking, running, walking or swimming.
  
• Get a good night's sleep. Sleep deprivation negatively impacts your mood and physical health. As noted above, insomnia can also be a trigger for manic episodes. For tips for achieving a good night's sleep, visit the National Sleep Foundation's website here. If none of these strategies work, tell your doctor as soon as possible, as sleep deprivation can be a trigger for worsening of your mood disorder.
  
• Eat right. Avoid empty calories such as refined sugar, soft drinks, white flour products and sweetened fruit juice. These high carbohydrate foods contain few nutrients and can cause blood sugar to fluctuate. Blood sugar directly affects mood, so keeping it stable is very important. Instead, focus on fruits, unprocessed fruit juices, fresh vegetables and whole grains. Excessive caffeine should also be avoided because it is a stimulant and can trigger panic attacks.
  
• Avoid alcohol and drugs. Alcohol and drugs aggravate anxiety, can trigger panic attacks and can make mood episodes worse.
  

What steps should family and friends take to help someone with an anxiety disorder and bipolar disorder?

Family support is an important part of the recovery process for both anxiety disorders and bipolar disorder. Some things family members can do to help a loved one diagnosed with these disorders include:

• Learn about the disorder(s).
  
• Recognize and praise small accomplishments.
  
• Modify expectations during stressful periods.
  
• Measure progress on the basis of individual improvement, not against some absolute standard.
  
• Be flexible and try to maintain a normal routine.
  
• Keep track of symptoms. Loved ones may notice a change in behavior or symptoms before the person suffering from them does, and treatment modification based on these changes can help stave off a severe episode.
  
• Provide ongoing encouragement during the treatment process, and help your loved one be consistent with their treatment plan. It can be hard for people to always take their medication or keep therapy appointments when they are not feeling well. It may also take a while to find the best treatment plan for each individual.
  
• Make a clear plan for emergency situations should symptoms become severe or hospitalization becomes necessary.

Family members should also keep in mind that the recovery process is stressful for them as well. They should build a support network of relatives, friends and, when necessary, therapists for themselves. Remember that with proper treatment by a mental health professional, anxiety disorders and bipolar disorder can be overcome.

Can children suffer from co-occurring anxiety and bipolar disorders?

Yes, many children who suffer from bipolar disorder suffer from one or more co-occurring anxiety disorders. The age of onset for an anxiety disorder often precedes the age of onset for bipolar disorder in children. Having both disorders can worsen the symptoms and course of each individual disorder, making it essential for parents and doctors to place an emphasis on treating both conditions. Sometimes the pronounced symptoms of bipolar disorder, such as severe mood swings and extreme irritability, may mask underlying obsessive thoughts, compulsions, worries or other anxiety symptoms. This makes it important for children with bipolar disorder to also undergo an assessment for anxiety disorders.

How can I help my child?

If you think your child is exhibiting symptoms of anxiety and/or bipolar disorder, it is important to consult a mental health provider or physician as soon as possible. For information on when to seek help for your child and tips on finding the right professional, click here. You can also find more information about finding a therapist for a child and questions to ask on the Child & Adolescent Bipolar Foundation's website here.

References and Resources

Child & Adolescent Bipolar Foundation

Depression and Bipolar Support Alliance

Journal of Clinical Psychiatry: Bipolar Disorder and Comorbid Anxiety Disorders in Children and Adolescents

Massachusetts General Hospital

Medscape: Anxiety and Bipolar Disorder

Mental Health America

National Alliance on Mental Illness

National Institute of Mental Health

Psychiatry Weekly: Bipolarity Presenting as Anxiety Disorders